Client Equipment Loan Deed Schedule

(For Equipment loans to be used mainly in the clients residence)

Item 1 - Client Details

Today’s Date:

First Name: Family Name:

Date of Birth: Sex: Diagnosis:

NDIS Client: Yes No

Item 2 – Hirer Details

Title: First Name: Family Name:

Relationship to Client (Parent/Guardian/Carer):

Address:

Postal Address (if different to address):

Phone: (H) (W) (M)

Email address:

Item 3 - Clinician Details

Title: First Name: Family Name:

Profession: Agency/Team:

Address: Work Phone Number:

Item 4 – Equipment Details and Due Date
Note: Equipment loans for loan items to clients are for an initial period of 3 months and a maximum extension of 3 months, assessment items are for an initial period of 2 weeks and a maximum extension of 2 weeks.

Equip Item No

/

Description

/ Accessories List
Required
(office use only) / Approx Cost of Item /

Condition of Equipment

/

Date Equipment Required

/ Returned Date
(Office use only)

The above items of equipment have been prescribed and/or recommended by the clinician listed in Item 3 of this form, for sole use by the client listed in Item 1 of this form.

If equipment is to be delivered please complete delivery request on next page.

Item 5 - Delivery of Equipment (please complete ONLY if equipment is to be delivered)

Delivery Date:

Delivery Address:

Person who will accept delivery: Phone Number:

Have you discussed delivery with client: No Yes

Special Instructions:

Item 6 - Collection of Equipment (please complete if collection date is known)
Date for Collection:
Collection Address:
Person who will attend collection:
Have you discussed collection with client: No Yes
Special Instructions:
Item 7 – Insurance
The Equipment is to be insured under the Hirer’s contents policy for the Premises – Yes / No.

Executed as a Deed

By signing this Deed the Hirer acknowledges that the Client Equipment Loan Deed Terms and Conditions apply and the Hirer agrees to be bound by those terms and conditions. The Hirer also acknowledges having received and read a copy of the Client Equipment Loan Deed Terms and Conditions.

DATE OF THIS AGREEMENT 20

Execution by the Hirer:
SIGNED, SEALED AND DELIVERED
By
[Insert Full Name of the CLINICIAN]
in the presence of:
………………………………………….…
Signature of witness
…………………………………………….
Print name / )
)
) / ……………………………………….
Signature of Hirer
……………………………………….
Print name

Note

Date: Must be dated on the date of executing this Deed.

Individual: Must be signed by the Hirer and witnessed.

Please contact CAYPELS:
·  If you are having difficulty using the equipment
·  For all equipment repairs.
·  To arrange return of equipment
·  For general enquiries regarding the equipment
CAYPELS Contact Details
Ph: 6205 1277 Email: Fax: 62051266